U15 (Bantam) White COVID Screening Form (Manvers Minor Hockey)

Print U15 (Bantam) White COVID Screening Form
This screening tool must be completed by each participant prior to participation in each on-ice or off-ice activity THIS MUST BE COMPLETED IN THE 2 HOUR WINDOW BEFORE THE SCHEDULED ICE TIME. If you have answered "YES" to any of the questions below, you are not permitted to participate in any on-ice or off-ice activities. This form has been developed based on the Ontario Ministry of Health Self-Assessment Tool (September 14, 2020) and included as part of the OMHA Return to Hockey planning.
  1. If you are in any of the following at risk groups, we ask that you speak with your physician prior to participating.

    • Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors)

    • Having a condition that compromises (weakens) your immune system (for example, lupus, rheumatoid arthritis, immunodeficiency disorder)

    • Having a chronic (long-lasting) health condition (for example, diabetes, emphysema, asthma, heart condition, COPD)

    • Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment)

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  3. Pre-Screening Details

    Are you currently experiencing any of these issues? Call 911 if you are.

    • Severe difficulty breathing (struggling for each breath, can only speak in single words)

    • Severe chest pain (constant tightness or crushing sensation)

    • Feeling confused or unsure of where you are

    • Losing consciousness

  4. Are you currently experiencing any of these symptoms? 

    • Do you have a fever? (Feeling hot to the touch, a temperature of 37.8C or higher) or Chills?

    • Cough that’s new or worsening? (continuous, more than usual) or a barking cough?, making a whistling noise when breathing? (croup)

    • Shortness of breath? (out of breath, unable to breathe deeply)

    • Sore throat? Difficulty swallowing?

    • Runny nose, sneezing or nasal congestion? (not related to seasonal allergies or other known causes or conditions)

    • Lost sense of taste or smell?

    • Pink eye? (conjunctivitis)

    • Headache that’s unusual or long lasting?

    • Digestive issues? (nausea/vomiting, diarrhea, stomach pain)

    • Muscle aches?

    • Extreme tiredness that is unusual? (fatigue, lack of energy)

    • Falling down often?

    • For young children and infants: sluggishness or lack of appetite?

  5. For the remaining questions, close physical contact means: 

    Being less than 2 metres away in the same room, workspace, or area for over 15 minutes living in the same home. 

    In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?

    2.  In the last 14 days, have you been in close physical contact with a person who either: Is currently sick with a new cough, fever, or difficulty breathing; OR Returned from outside of Canada in the last 2 weeks? 

    Have you travelled outside of Canada in the last 14 days?

Human Validation
Printed from manvershockey.com on Tuesday, October 20, 2020 at 10:38 PM